Patient Needs, Required Level of Care, and Reasons Delaying Hospital Discharge for Nonacute Patients Occupying Acute Hospital Beds

Short-term mortality and palliative care use after delayed hospital discharge: a population-based retrospective cohort study

OBJECTIVES

In Canada, patients whose acute medical issues have been resolved but are awaiting discharge from hospital are designated as alternate level of care (ALC). We investigated short-term mortality and palliative care use following ALC designation in Ontario, Canada.

METHODS

We conducted a population-based retrospective cohort study of adult, acute care hospital admissions in Ontario with an ALC designation between January and December 2021. Our follow-up window was until 90 days post-ALC designation or death. Setting of discharge and death was determined using admission and discharge dates from multiple databases. We measured palliative care using physician billings, inpatient palliative care records and palliative home care records. We compared the characteristics of ALC patients by 90-day survival status and compared palliative care use across settings of discharge and death.

RESULTS

We included 54 839 ALC patients with a median age of 80 years. Nearly one-fifth (18.4%) of patients died within 90 days. Patients who died were older, had more comorbid conditions and were more likely to be male. Among those who died, 35.1% were never discharged from hospital and 20.3% were discharged but ultimately died in the hospital. The majority of people who died received palliative care following their ALC designation (68.1%).

CONCLUSIONS

A significant proportion of patients experiencing delayed discharge die within 3 months, with the majority dying in hospitals despite being identified as ready to be discharged. Future research should examine the adequacy of palliative care provision for this population.

Identification of implementation enhancement strategies for national comprehensive care standards using the CFIR-ERIC approach: a qualitative study

BACKGROUND

Comprehensive care is important for ensuring patients receive coordinated delivery of healthcare that aligns with their needs and preferences. While comprehensive care programs are recognised as beneficial, optimal implementation strategies in the real world remain unclear. This study utilises existing implementation theory to investigate barriers and enablers to implementing the Australian National Safety and Quality Health Service Standard 5 - Comprehensive Care Standard in acute care hospitals. The aim is to develop implementation enhancement strategies for work with comprehensive care standards in acute care.

METHODS

Free text data from 256 survey participants, who were care professionals working in acute care hospitals across Australia, were coded using the Consolidated Framework for Implementation Research (CFIR) using deductive content analysis. Codes were then converted to barrier and enabler statements and themes using inductive theme analysis approach. Subsequently, CFIR barriers and enablers were mapped to the Expert Recommendations for Implementing Change (ERIC) using the CFIR-ERIC Matching Tool, facilitating the development of implementation enhancement strategies.

RESULTS

Twelve (n = 12) CFIR barriers and 10 enablers were identified, with 14 barrier statements condensed into 12 themes and 11 enabler statements streamlined into 10 themes. Common themes of barriers include impact of COVID-19 pandemic; heavy workload; staff shortage, lack of skilled staff and high staff turnover; poorly integrated documentation system; staff lacking availability, capability, and motivation; lack of resources; lack of education and training; culture of nursing dependency; competing priorities; absence of tailored straties; insufficient planning and adjustment; and lack of multidisciplinary collaboration. Common themes of enablers include leadership from CCS committees and working groups; integrated documentation systems; established communication channels; access to education, training and information; available resources; culture of patient-centeredness; consumer representation on committees and working groups; engaging consumers in implementation and in care planning and delivery; implementing changes incrementally with a well-defined plan; and regularly collecting and discussing feedback. Following the mapping of CFIR enablers and barriers to the ERIC tool, 15 enhancement strategies were identified.

CONCLUSION

This study identified barriers, enablers, and recommended strategies associated with implementing a national standard for comprehensive care in Australian acute care hospitals. Understanding and addressing these challenges and strategies is not only crucial for the Australian healthcare landscape but also holds significance for the broader international community that is striving to advance comprehensive care.

The implementation and impacts of the Comprehensive Care Standard in Australian acute care hospitals: a survey study

BACKGROUND

Comprehensive care (CC) is becoming a widely acknowledged standard for modern healthcare as it has the potential to improve health service delivery impacting both patient-centred care and clinical outcomes. In 2019, the Australian Commission on Safety and Quality in Health Care mandated the implementation of the Comprehensive Care Standard (CCS). However, little is known about the implementation and impacts of the CCS in acute care hospitals. Our study aimed to explore care professionals' self-reported knowledge, experiences, and perceptions about the implementation and impacts of the CCS in Australian acute care hospitals.

METHODS

An online survey using a cross-sectional design that included Australian doctors, nurses, and allied health professionals in acute care hospitals was distributed through our research team and organisation, healthcare organisations, and clinical networks using various methods, including websites, newsletters, emails, and social media platforms. The survey items covered self-reported knowledge of the CCS and confidence in performing CC, experiences in consumer involvement and CC plans, and perceptions of organisational support and impacts of CCS on patient care and health outcomes. Quantitative data were analysed using Rstudio, and qualitative data were analysed thematically using Nvivo.

RESULTS

864 responses were received and 649 were deemed valid responses. On average, care professionals self-reported a moderate level of knowledge of the CCS (median = 3/5) and a high level of confidence in performing CC (median = 4/5), but they self-reported receiving only a moderate level of organisational support (median = 3/5). Only 4% (n = 17) of respondents believed that all patients in their unit had CCS-compliant care plans, which was attributed to lack of knowledge, motivation, teamwork, and resources, documentation issues, system and process limitations, and environment-specific challenges. Most participants believed the CCS introduction improved many aspects of patient care and health outcomes, but also raised healthcare costs.

CONCLUSION

Care professionals are confident in performing CC but need more organisational support. Further education and training, resources, multidisciplinary collaboration, and systems and processes that support CC are needed to improve the implementation of the CCS. Perceived increased costs may hinder the sustainability of the CCS. Future research is needed to examine the cost-effectiveness of the implementation of the CCS.

Associations Between Psychiatric Diagnoses on Length of Stay and Mortality After Rib Fracture: A Retrospective Analysis

INTRODUCTION

Concurrent psychiatric diagnoses adversely impact outcomes in surgical patients, but their relationship to patients with rib fracture after trauma is less understood. We hypothesized that psychiatric comorbidity would be associated with increases in hospital length of stay (LOS) and mortality risk after rib fracture.

MATERIALS AND METHODS

The 2017 National Inpatient Sample was queried for adult patients who were admitted with rib fracture after trauma. Mental health disorders were categorized into 34 psychiatric diagnosis groups (PDGs) using clinical classifications software refined for International Classification of Diseases-10. Outcomes of interest were LOS and mortality. Bivariable analysis determined associations between PDGs, patient demographics, hospital characteristics, and outcomes. Logistic regression was performed to identify adjusted effects on mortality, and linear regression was performed to identify effects on LOS.

RESULTS

Of 32,801 patients, median age was 61 y (IQR 46-76), and median LOS was 5 d (IQR 3-9). No PDGs were associated with increased odds of mortality. Concurrent diagnosis of schizophrenia spectrum (Coeff. 3.5, 95% CI 2.7-4.4, P < 0.001) or trauma- or stressor-related (Coeff. 1.6, 95% CI 0.9-2.5, P < 0.001) disorders demonstrated the greatest association with prolonged LOS. Increased odds of death and prolonged hospital stay were also associated with male sex, non-White patient race, and surgery occurring at urban and public hospitals.

CONCLUSIONS

Psychiatric comorbidities are associated with death after rib fracture but are associated with increased LOS. These findings may help promote multidisciplinary patient management in trauma.

Decreasing the Frequency of Nursing Assessment for Medically Stable Hospitalized Patients

PURPOSE/OBJECTIVES

During the COVID-19 pandemic, a large Midwest tertiary care medical center had prolonged hospitalizations due to strained staffing and few options for post-acute care recovery. Patients deemed medically ready for discharge were receiving the same care interventions as all other hospitalized medical-surgical patients. The study objective was to appropriately match care assessment frequency for these patients with their individual needs by reducing the frequency of routine nursing assessments.

DESCRIPTION OF THE PROJECT/PROGRAM

This quality improvement initiative reduced the frequency of nursing assessments, including routine monitoring of vital signs, to once daily for medically stable patients whose discharge was delayed.

OUTCOME

During the 4-week pilot, 40 hospitalized patients were enrolled; 960 assessments were eliminated, and nurses were able to reallocate approximately 500 hours to other nursing tasks. No adverse outcomes were observed among patients who received once-daily assessment.

CONCLUSION

By decreasing nursing assessment frequency for hospitalized patients with discharge delays, nurses appropriately matched care interventions with the patient's needs.

Optimising the discharge process in internal medicine in Québec: A qualitative interpretive descriptive study to understand the challenges faced by healthcare professionals

Optimising the discharge process for internal medicine programs is a challenge given multiple social and practical constraints in transitions from hospital to home. The objective of this study is to explore healthcare professionals' perspectives on discharge processes in internal medicine within a context of organisational reform. This is an interpretive descriptive qualitative study using in-depth individual interviews with healthcare providers. Seventeen semi-structured interviews were conducted. The study comprised a sample of 18 healthcare professionals working on two internal medicine wards in an acute care teaching hospital in Quebec. A conceptual framework comprising core aspects of the discharge process (planning, coordination, teaching and outcomes) guided data collection and analysis. Thematic analysis was applied to analyse the data. Major themes were developed by contrasting empirical data and the conceptual framework. Five themes were developed (1) Iterative discharge planning; (2) Patient and family engagement in discharge planning and discharge readiness, (3) Lack of time for discharge teaching, (4) Discharge coordination and the placement of patients and (5) Inequitable social support and resources and risk of readmission. This study highlights the inter-relationship between discharge readiness and phases of the discharge process, in particular planning and coordination. Iterative planning along with strategies to coordinate discharge constitute efforts to ensure flexible processes that respond to patients' needs and preferences. Challenges persist for healthcare professionals regarding autonomy and resources, along with reduced opportunities for patient and family engagement in decision-making.

Effects of a level-of-care tool on admission placement and rapid response use

Nurses promote performance improvement efforts that advance the practice of nursing and enhance outcomes. This special section highlights three successful performance improvement initiatives that showcase the value of these efforts.

Getting Unstuck: Challenges and Opportunities in Caring for Patients Experiencing Prolonged Hospitalization While Stable for Discharge

Many physicians care for patients who remain in the hospital for prolonged periods despite being "medically ready" or stable for discharge. However, this phenomenon is not well-defined, and optimal strategies to address the problem are not known. A prolonged hospitalization past the point of medical necessity can harm patients, frustrate care teams, and is costly for the health care system. In this perspective, we describe opportunities to improve value of care for these patients through the lens of the Quadruple Aim, a common framework used to guide health care transformation efforts. We then offer recommendations, including some employed by our hospitals, for clinicians, researchers, and health care systems to improve the care for patients who are "stuck" in the hospital.

Delayed discharges from a tertiary teaching hospital in Israel- incidence, implications, and solutions

Objectives

The Israeli health system is facing high workloads with average occupancy in certain hospital wards of around 100%. Since there is a shortage of hospitalization beds in institutions for continuous, long-term care, transferring patients from the general hospitals’ wards is often delayed. This situation has many significant ramifications, to the waiting patients themselves, to other patients who are waiting to be treated and to the entire organization. In this study, we describe the phenomenon of the “detained patients” - its extent, characteristics, significance, and possible solutions.

Materials and methods

Rambam Health Care Campus is a tertiary medical center serving the population of the northern part of Israel. In recent years, the hospital management documents data regarding the “detained patients”. We reviewed hospital data of detained patients over a period of nine months. The data concerning adult patients awaiting transfer to an institution for continuous care, between May 2019 and January 2020, were obtained retrospectively from the computerized database of the social service.

Results

During the study period, 12,723 adult patients were discharged. Of those, 857 patients (6.74%) were transferred to one of the facilities providing prolonged institutional care. For that group of patients, median inpatient waiting time from the decision to discharge until the transfer was 8 days (IQR 6–14), translating to 10,821 waiting days or 1202 hospitalization days per month. These hospitalization days account for 9.35% of the total hospitalization days during the study period. The “detained patients” were hospitalized in internal medicine wards (32%), orthopedic (30%), and neurology/neurosurgery (26%) departments. At any given moment, about 40 hospitalized patients were waiting for long-term care facilities.

Conclusions

Health-care systems must adapt to the current patients’ case-mix to achieve optimal utilization of hospital beds and maximal operational efficiency. The number of long-term care beds should be increased, the coordination between general hospitals, health maintenance organizations and long-term facilities improved, and patients that may require long term care after the acute phase of their illness should be early identified and addressed. Meanwhile, establishment of organic units for waiting patients and reorganization of the hospital structure should be considered.

Reallocating Cancer Surgery Payments for Alternate Level of Care in Ontario: What Are the Options?

This article examines how alternate-level-of-care (ALC) days are funded through the cancer surgery funding model in Ontario and evaluates policy options to better address ALC days. The contribution of ALC days to hospital funding and the impact of removing or reallocating this funding from cancer surgery is measured. Though costs associated with ALC days in cancer surgery are low, this article highlights the need for policy options that would realign funding across the healthcare system in Ontario to better meet the needs of patients waiting for ALC, reduce pressure on inpatient bed capacity and improve value for money.

A long wait: barriers to discharge for long length of stay patients

Introduction

Reducing long length of stay (LLOS, or inpatient stays lasting over 30 days) is an important way for hospitals to improve cost efficiency, bed availability and health outcomes. Discharge delays can cost hundreds to thousands of dollars per patient, and LLOS represents a burden on bed availability for other potential patients. However, most research studies investigating discharge barriers are not LLOS-specific. Of those that do, nearly all are limited by further patient subpopulation focus or small sample size. To our knowledge, our study is the first to describe LLOS discharge barriers in an entire Department of Medicine.

Methods

We conducted a chart review of 172 LLOS patients in the Department of Medicine at an academic tertiary care hospital and quantified the most frequent causes of delay as well as factors causing the greatest amount of delay time. We also interviewed healthcare staff for their perceptions on barriers to discharge.

Results

Discharge site coordination was the most frequent cause of delay, affecting 56% of patients and accounting for 80% of total non-medical postponement days. Goals of care issues and establishment of follow-up care were the next most frequent contributors to delay.

Conclusion

Together with perspectives from interviewed staff, these results highlight multiple different areas of opportunity for reducing LLOS and maximising the care capacity of inpatient hospitals.

Analysis of the Perroca Scale in Palliative Care Unit

Objective To analyze the complexity of nursing care with use of the Perroca scale in a Palliative Care Unit. Method Retrospective descriptive study of quantitative analysis. Results Between 2008 and 2016, the total of 2,486 patients were hospitalized, and their median length of hospital stay was 12 days. Of these patients, 1,568 had at least one Perroca scale evaluation. Nine hundred and ten patients (58%) were classified as minimal or intermediate care. Of these, 602 (66%) were discharged. As semi-intensive and intensive care were classified 658 (42%) patients, of whom 64% died and only 36% were discharged. Conclusion The Perroca scale is a tool to identify patients with greater need for care and the possible prognosis for hospitalized patients.